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REPORT ON VIRTUAL HOSPITAL
FRAMEWORK
Department
Hospital Administrator/CEO
Presented
To
Dr Faisal Haq
Faculty Hospital Administration
Institute of Business management
By
Dr Shahida Mirza
ID-9636
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Table of ContentsCEO/HOSPITAL ADMINISTRATOR ................................................................................................................... 3
Administrator ............................................................................................................................................. 5
POLICY ............................................................................................................................................................ 5
Objectives ....................................................................................................................................................... 6
Procedures ..................................................................................................................................................... 7
Programs ........................................................................................................................................................ 7
Standards ........................................................................................................................................................ 8
Duties & Responsibilities ................................................................................................................................ 9
Logistics............................................................................................................................................ 11
Long-Term Planning ......................................................................................................................... 11
Policies ............................................................................................................................................. 11
Organogram ................................................................................................................................................. 12
Hospital Environment ................................................................................................................................... 13
Macro Environment ................................................................................................................................. 13
Micro Environment .................................................................................................................................. 13
Objectives ................................................................................................................................................. 14
POLICIES ................................................................................................................................................... 14
Fire Safety Services ................................................................................................................................... 15
Environment Management Services ........................................................................................................ 16
Occupational safety & Health services ..................................................................................................... 17
By-Laws in general ........................................................................................................................................ 20
Departmental By-Laws ................................................................................................................................. 21
BY-Laws Directly Related to Patient Care ..................................................................................................... 21
AIR-CONDITIONING OF HOSPITAL ................................................................................................................ 23
OBJECTIVES ................................................................................................................................................... 25
POLICIES OF FINANCE DEPARTMENT (FD) .................................................................................................... 26PROCEDURES OF FINANCE DEPARTMENT .................................................................................................... 27
HOSPITAL'S ANTI-FRAUD BYLAWS ............................................................................................................... 28
DEPARTMENTAL WORK FLOW ..................................................................................................................... 30
INTERDEPARTMENTAL HIERARCHY .............................................................................................................. 31
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STAFFING ...................................................................................................................................................... 32
SOURCES OF REVENUE (FUNDING) ................................................................. Error! Bookmark not defined.
HOSPITAL BUDGETING ................................................................................................................................. 33
Hospitals Budget Calendar .......................................................................................................................... 39
HUMAN RESOURCE DEPARTMENT.................................................................. Error! Bookmark not defined.
INTER DEPARTMENTAL HIERARCHY ................................................................ Error! Bookmark not defined.
Medical Department .................................................................................................................................... 40
Summarized History Of Nursing: .................................................................................................................. 53
RADIOLOGY DEPARTMENT ........................................................................................................................... 82
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CEO/HOSPITAL ADMINISTRATOROne of the most important assets of any community is a hospital. A hospital is a
resource for anyone needing emergency medical attention or care beyond what a
physician's office can provide. A hospital is staffed by a multitude of employees,
and in such a busy, complex environment, there must be someone who canorganize and coordinate all of the people and services that are required. This role
is fulfilled by a hospital administrator, the person who oversees everything that
goes on in a hospital.
Our Hospital Administration Classis committed to building an exemplary patient
care community that offers a nurturing and challenging intellectual climate, a
respect for the spectrum of human diversity, and a genuine understanding of the
many differences-including race, ethnicity, gender, age, socio-economic status,
national origin, sexual orientation, disability and religion that will enrich theVirtual Hospital community.
Hospital is an organization that mobilizes the skills and efforts of widely divergent
group of professionals and semi-professionals, so as to provide highly personalized
services to individual patients.
It is therefore essential to bring together the various components to a unified
whole to achieve the objective through the authority of central co-ordination. This
warrants a systematic functioning of a hospital as an institution.
The Word HOSPITAL is self explanatory as it is given below:
H - HEALING
O - OBSERVATION
S - SUPERVISION
P - PERSUATION
I - INVESTIGATION
T - TREATMENT
A -ASSURANCE
L -LIESURE
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AdministratorIn addition to the care provided to the patients by the physicians and nurses, most
medical facilities require a significant amount of behind-the-scene administrative
support. Hospital Administrators are the professionals responsible for managing
hospitals.
The hospital administrator plays a vital a role in saving lives, without having to
take scalpel in hand.
Hospital administrators manage hospitals, outpatient clinics, hospices, and drug-
abuse treatment centers.
In large hospitals, there may be several administrators, one for each department.
In smaller facilities, they oversee the day-to-day operations of all departments.
The doctors strive to keep the blood flowing and the heart beating,
BUT
The hospital administrator is doing his job in keeping the hospital alive and
healthy.
POLICY To make sure that hospitals are operating efficiently& providing
adequate medical care to the patients.
To act as Liaison between Governing Boards, Medical staff, &
Department head.
To integrate the activities of all departments so they function as a whole
Toplan, organize, direct, control & co-ordinate medical & health services
following policies set by a governing board of trustees.
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To recruit, hire and sometimes train doctors, nurses, interns & assistant
administrators to develop a stable staff.
To develop strengths and neutralize workers weaknesses.
To develop procedures for medical treatments (in collaboration with
consultants), quality assurance, patient services, and public relations
activities such as community health.
To attendstaff meetings & participate in health planning councils.
They need to keep up with advances in:
- Medicine,
- Computerized diagnostic & treatment equipment,
- Data processing technology,
- Government regulations,
- Health insurance changes
- Financing options
ObjectivesDirecting hospital activities according to governing boards overall
objectives & policies.
Reviewing departments reports and activities
Settlingpatients complaints.
Assembling competent workers to direct & undertake given activities & to
develop them useful environmental and medical teams.
Preparing& operating sound financial structure& effective control & safety
of funds.
Submitting a long term plan for hospital and growth & a periodic, annual
financial budget to the Governing Boardfor its approval or otherwise.
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Studying advances in hospital practices in order to advise the Governing
Board.
Studying the means to meet the communitys changing hospital needs.
ProceduresWriting proposals for government grants.
Preparing periodic budgets.
Allocating scarce funds & other resources.
Determining patients fee Schedule.
Determining space, equipment, materials & human resource needed to
provide services.
Convening conferences.
Determining on-duty schedule for Administration Department.
Makinga formal inspection round.
ProgramsFire Prevention and Fighting:
Prevention of fires by documented regular inspections of facilities and fire-
fighting equipment, and drills.
Disaster:
Expeditious care of mass casualties from a catastrophe and maintenance of
services during disrupted utility supplies, workers strikes, and guerilla
attacks
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Safety:
Documents periodic inspections of facilities and job procedures to prevent
accidents which may cause death, injury, loss of time, lowered morale, and
increased accident insurances
Noise : reviews outside unwelcome sound about which little can be done
and inside excessive television and radio volume, door slamming, and
equipment squeaking wheels about much can be done
Time Conservation:
Involves prompt and accurate information, managers delegation of routine
tasks and elimination of indecision and orderly arrangement of items at
work place to obviate searching
Quality Patient Care:
Documents periodic review of patients needs for good care and evaluation
of departments coordinated activities and resources to meet such needs
Patients Suggestions:
Invitation, acknowledgement, consideration with appropriate department,and acceptance, if suitable, of patients suggestions for service importance
StandardsFor the Administrators periodic report
- To ensure uniform presentations,
- Prevent omission & duplications
- Facilitate comparison with previous reports.
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For the quantity of patient care,
- Total patients days
- Outpatient Attendances
- Social Service Visit
For Quality of Care
- No. of clinical tests performed
Resources used
- Staff man-hours paid
- Pounds of soiled linen processed
For Quality of Resources Used
- By workers qualifications and secretaries shorthand and typing speed.
Duties & ResponsibilitiesThere are many duties of an administrator, but regardless, they are just as vital to
patients lives as regular doctors and nurses are.
Supervision
The main responsibility of hospital administrators is to supervise and oversee the
daily operations of the hospital facility or the department(s) for which they are in
charge. They must be sure that the facility in which they work is operating in an
adequate and efficient manner to provide the best care possible to patients.
Communication
It's a large responsibility of hospital administrators to hold good communication
skills. Because they act as the main communicator between medical staff, medical
governing boards, and the heads of other medical departments, communication is
vital to the success of all involved, so all departments within a facility can function
together.
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They must also be sure to follow all policies and guidelines that are set by the
medical board of trustees, and they must be sure that the medical staff they are in
charge of supervising follows these policies as well.
Staff Hiring
Hospital administrators are responsible for the hiring of most staff, including
physicians, nurses and support staff. For elite positions, such as surgeons or other
kinds of specialists, the administrator may work to recruit top candidates.
Co-ordination of Business Functions
Most hospitals have a variety of business and support functions, and the hospital
administrator coordinates and oversees these functions. In a small hospital, the
administrator may handle these tasks directly. In a larger hospital, assistants and
managers may be appointed to handle various business and support functions, but
the hospital administrator will still oversee their work.
Policy Development & Implantation
Every hospital has its own set of policies that govern employees, procedures and
services offered to patients. A hospital administrator may be required to develop
policies and procedures and ensure that they are followed, or he may implement
policies created by a governing board or body. Short-range and long-range plans
for a hospital's development and overall growth are also usually handled, or at
least supervised, by a hospital administrator.
Managing Patients records
A large part of the hospital administrator's job concerns managing patient records.
The administrator must make sure that medical histories, current health
information, and billing, insurance and legal documents are all being handled
appropriately. Keeping all of this information organized and up to date is an
essential role that a hospital administrator must fill.
Employee Evaluation
As part of their hiring duties, hospital administrators must perform regular
evaluations of employees, rating them for competency and performance. This can
lead to promotions, demotions, transfers and firings.
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Public Relations
Hospital administrators will often act as the public face of a hospital, appearing at
professional conventions, meetings, public events and health planning councils.
They must present the hospital in a good light and facilitate interactions with the
community.
Program Development
Hospital administrators are also responsible for various kinds of program
development. Programs can include different approaches to treatment, as well as
ones that relate to the hospital's organizational and managerial structure. Most
programs begin by identifying a need, either among patients or health-care
providers, and developing solutions to address it, which can then be formalized
into a new or designed program or initiative.Budget
Hospital administrators are responsible for helping to prepare the hospital's
budget, assessing priorities and allocating resources to various departments and
programs. After the budget has been prepared and approved, administrators must
supervise its implementation.
Logistics
Hospital administrators are also responsible for overseeing a hospital's logisticalconcerns. This includes organizing the hospital's supply chain to ensure that
physicians and nurses consistently have resources, such as medical supplies, to
provide appropriate patient care.
Long-Term Planning
Hospital administrators are also responsible for planning the hospital's future in
the long term. This includes outlining the hospital's future goals, identifying likely
challenges, and making sure that financial and logistical resources are in place to
accomplish the facility's mission.Policies
Hospital administrators must help develop and implement hospital policies,
making sure they meet the needs of patients and staff, and that they are
consistent with the requirements set forth by the hospital's board of directors.
They should also ensure that all policies comply with applicable laws.
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Organogram
CEO/Administrator
Chief Operational Officer
Manager Nursing Chief Medical OfficerAssistant Manager
Operation
Dietary Services Maintenance
House Keeping Social Services
Pharmacy Laboratory
Radiology
Chief Financial Officer
Assit. Manager Income
Assit. Manager Expense
Accountant
Human Resource
Manager Recruitment
Manager Appraisal
Manager Training
DepartmentSecretary
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Hospital EnvironmentHospital Environmental Service is about more than just cleanliness. A hospitals
appearance is the first opportunity to make an impression on patients and
visitors.
Creating a clean and safe facility builds confidence in services and translates into
improved patient satisfaction
Environmental Services is an integral part of the hospital team, and its work
directly impacts not only the daily operations of the hospital, but also the most
important deliverables: satisfaction and outcomes
Environment affects hospital functioning in two aspects
Macro Environment
- Overall Law & Order situation of city.
- General Economics and paying capacity of the population of Catchment area
of hospital.
- Disturbance in the community declines productivity of staff, e.g Riots,
strikes & transportation difficulties.
- Industrial noise and vibration disturbs delicately balanced scientific
equipments.
- High humidity, intense heat and desert dust bearing winds permeate
equipment mechanism.
Micro Environment
- Hospital itself (Shell, building, & physical assets)
- Segmentation of Climate
- Split of room categories
- Environment of LR, OR, ER, ICU, NICU etc
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Special emphasis on:
- Air conditioning
- Zoning
- Interior decoration
- Cross functional team with collaboration with other units
- Hygiene Standards
- Fire Safety
Objectives
The Department of Health & Safety Provides:
Programming
Processes
Training
As required by the Regulatory Standards & Regulatory agencies of Hospitals
EH&S staff serves as consultants to identify and resolve health & safety issues, aswell as Specialists on Hospital committees & provide Expertise in such areas such
as:
- Fire Safety
- Environmental Management
- Occupational safety & Health
- Radiation safety
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POLICIESTo Communicate & Facilitate all new program requirements & regulatory
initiatives.
To provide regulatory driven safety training.
To perform internal self audits and minor workplace hazards to insure
compliance.
To assess program compliance through
- Hazard surveillance rounds,
- Environmental rounds,
- Review of illness & injury reports
- Observation of staff knowledge during actual activities & planned drills
Following summarizes those services by program area:
Fire Safety Services
Regulatory Inspections
Conduct general inspection of facilities, life safety surveys, and compliance
surveys for compliance with applicable regulation and standards.
Fire Extinguisher Inspections
- Complete monthly inspections of all fire extinguishers.
- Annual maintenance of all extinguishers and hydrostatic testing of all of
them per code.
Fire Drills
Conduct quarterly drills covering all three drills.
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Emergency Response
Provide emergency response to fire alarms, accidents, medical emergencies
and hazardous materials incidents, as well as routine responses to requests
for assistance.
Fire Detection & Suspension System
Monitor and service Hospitals fire detection and suppression systems that
have more than 15,000 components, such as smoke detectors, heat
detectors, bells, manual pull stations and fixed extinguisher system.
Plan Review
Review, as requested, proposed Hospital rehabilitations or new facilities to ensurecompliance with all applicable codes and standards.
Special Events
Provide safety supervision at various large events and public assemblies, including
carnivals, concerts, and special activities.
Safety Training
Provide Fire Warden, Interim Life Safety and general Fire Safety training to
Hospital staff. General Fire Safety training is provided to the off-site facilities.
Accommodation for the Disabled
In accordance with the Americans with Disabilities Act, activities include the
retrofitting of Hospital facilities to incorporate visual fire alarms and evacuation
guidance for the visually impaired.
Environment Management Services
Hazardous Waste Collection and Disposal
Coordinate and guide Hospital staff on proper collection and disposal of chemical
hazardous waste, asbestos waste, PCB waste, including sampling and identification
of unknown waste substances.
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Recordkeeping
Maintain manifest and track waste disposal from Hospital operations.
Safety Training
Provide hazardous waste management training online, during orientation, andrecertification trainings.
Waste Minimization Program
Assist generators with regard to waste minimization. This may include training and
assisting in waste reclamation, conservation of raw materials, and less hazardous
product substitution. Identify strategies to recycle, reduce and reuse Hospital
resources.
Occupational safety & Health servicesHazard Surveillance
Hazard surveillance rounds are performed to ensure compliance with occupational
health and safety requirements, and Joint Commission, plus safety audits of all
operations and areas for potential occupational hazards and risks to employees.
Rounds at off-site facilities are performed by the Off-site
Safety Training
Conduct employee health and safety training on topics such as hazardcommunication protection, hearing conservation, and other specialized health and
safety topics.
Recordkeeping
Occupational injury and illness recordkeeping and reporting, including maintaining
injury and illness log and the summary.
Hazard Assessments
Hazard Assessments are performed to developed safety procedures for various
operations.
Injury and Illness Investigations
Conduct investigations to determine root causes and recommend corrective
action.
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Occupational Exposure Monitoring
Conduct chemical exposure monitoring for formaldehyde, ethylene oxide, waste
anesthetic gases, and other airborne contaminants.
Indoor Air Quality
Conduct indoor air quality surveys, including sampling, identifying and developing
appropriate remedial actions to eliminate potential sources of airborne
contaminants. At off-sites, sampling is performed by the Off-site EC Coordinator.
Noise and Hearing Conservation
Conduct personal and area noise monitoring, as needed.
Lab Safety
Implement the Hospitals Chemical Hygiene Plan and Laboratory Safety Plan,
including lab inspections and chemical fume hood inspections.
Asbestos Management
Manage the Hospitals asbestos abatement activities. Perform air and bulk
sampling. Perform operations and maintenance asbestos abatements.
Radiation Safety Services
Radiation Protection Services provide the health physics support services that
are mandated by the New York State Bureau of Environmental RadiationProtection in the University's Broad Radioactive Materials License.
Licensing Management for the Academic and Medical Programs
Manage the Hospital Radiation Protection Program and maintaining compliance
with mandated licensing conditions.
Radiation Surveys
Perform radiation protection surveys for all sources of ionizing radiation. Maintain
lead apron quality control monitoring program.Personnel Monitoring
Provide personnel monitoring services, including provision of monitoring devices,
interpretation of personnel monitoring exposure and maintenance of all records
of internal and external radiation exposure.
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Radiation Safety Training
Instruct personnel in the safe handling procedures of all sources of ionizing
radiation in accordance with University and State requirements.
Emergency Response
Respond to emergencies involving radioactive material.
Room Design and Decommissions
Participate in lead shielding design. Decommission and decontaminate authorized
radiation control areas to non-control area status.
Non-ionizing Radiation
Maintain the non-ionizing radiation safety program for lasers and microwaves, as
requested.
Hospital Radiation Protection
Provide full employee and patient protection services for radioactive materials
and ionizing radiation producing devices.
Radiation Waste Management
Manage low level radioactive waste management program
A.Off-site Facilities the services are provided to the off-siteEnvironmental services focal Points
Increase focus on patient care
Guarantee service outcomes
Maximize staff productivity
Improve revenue stream Ensure consistently high levels of cleanliness
Raise patient and staff satisfaction
Employ environmentally conscious cleaning practices
Prevent hospital-acquired infections
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By-Laws in general
1. Copy of policy available in all departments and senior in charge of the
department must be well acquainted with the document
2. Smartly dressed, respectful staff at reception area with all theinformation regarding the services available and the personnel
departmental designations.
3. Reception staff should have all the records of the out-patient & in-
patients attendance for visitors facilitation.
4. Strict compliance of visiting hours is mandatory.
5. Visiting of children under 7 years not allowed in the hospitals due to risk
of carrying the infections.
6. Childrens companions are requested to attend properly to visiting
children cautioning them to noisy and unruly behavior of the hospital.
7. No attendants should be allowed with the patients accept the visiting
hours.
8. Display of sign Boards of all facilities at the visible points.
9. More prominently placed FIRE EXIT sign boards
10.Fire drill schedules on weekly/ fortnightly basis
11.Daily round by day/ night supervisors to all departments.
12.Special emphasis on the decoration of the departments, waiting areas
and corridors to create the patient-friendly environment and easy
transfer of the patients.
13.Special emphasis on the cleanliness of the hospital shell is the
responsibility of the departments as well along with the hospital
supervisors.
14.Make a cleanup day as a fun activity.
15.Compliance of Security guards to clearly written instructions for thesafety of the patients, hospital staff and the important assets of the
hospital.
16.Complete awareness of the disturbances in the community surrounding
the hospital and the city in general which can affect the smooth
functioning of the hospital and their corrective measures.
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Departmental By-Laws
1. Duty roaster should be displayed at the soft board provided in the
department
2. Punctuality of duty time and the timely medication to the patients is
appreciated
3. Timely schedule of the Consultants appointment/visits for in-patients
4. Proper documentation of the in-patients regarding medication &
investigations or any scheduled procedure on the patient.
5. Preparation of patient and handing- taking from ER,OR as per requirement
of the procedure.
6. Timely disposal of the patient as per requirement of the medical record
office and billing department.
7. Proper documentation of the services availed by the patients to avoid extra
burden of cost for patients billing.
8. Proper management of all types of inventories and their turnover times
9. Quality assurance in patient care
10.All equipments should carry a tag with clearly written operating and
maintenance instructions
11.All the requisitions for lab, radiology and pharmacy should be online
(Provided the excellent HMIS is available), otherwise on properly designedforms with dispatch and receipt record.
12.Proper waste disposal by the department in collaboration with waste
disposal management department.
13.Requisition of the material according to the P &P of the MM department.
14.Billing of patients services strictly on their actual utilization by the patients.
BY-Laws Directly Related to Patient Care
1. A general consent form, signed by or on behalf of every patient admitted to
the hospital, must be obtained at the time of admission.
2. Documented evidence of such informed consent shall be included in the
patient's medical record.
3. All orders for treatment and medication shall be in writing.
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4. The practitioner's orders must be written clearly, legibly and completely.
Orders which are illegible or improperly written will not be carried out until
rewritten or understood by the nurse.
5. All previous orders are canceled when patients go to surgery.
6. All drugs and medications administered to patients shall be those listed inthe latest edition of Pharmacopoeia and National Formulary.
7. Consultations shall be obtained at the discretion of the attendingpractitioner.
8. The attending practitioner is primarily responsible for requesting
consultation when indicated and for calling in a qualified consultant. He will
provide written authorization to permit another attending practitioner to
attend or examine his patient except in an emergency.
9. In an effort to ensure an environment conducive to the delivery of quality
patient care, it is imperative that both Medical Staff and Hospital Staffconduct themselves in a professional, collaborative manner which is not
abusive or harassing. Any behaviors inconsistent with this goal should be
reported and addressed immediately.
The following behaviors are not acceptable in the workplace which, if exhibited,
will result in disciplinary action:
Breaching patient confidentiality;
Creating a hostile environment (by offensive language or other behavior)for patients, staff or Medical Staff members;
Stealing or other forms of dishonesty;
Threats or intimidation;
Violation of Hospital Business Conduct and Code of Ethics;
Violation of Patient Bill of Rights;
Violation of Sexual Harassment Policy;
Violation of the Drug Free Workplace Policy;
If not exhibited, then liable to disciplinary action
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AIR-CONDITIONING OF HOSPITAL
As all the hospital building cannot be set at the same temperature, it is imperative
to provide the air-conditioning on the priority of services, departmental
requirements. It is considered on the following basis.
i. Less air conditioning is required in corridors which have multiple entry
and exit areas.
ii. Operation theaters, labor rooms, ICU, NICU and other procedure rooms
require constant air- conditioning according to the season or the
departmental requirement.
iii. Radiology department needs different temperature for its equipments.
iv. Pharmacy needs different temperature for the storage of different typesof drugs.
v. Laboratorys needs for air-conditioning should be according to the
performance of test and the desired temperature.
vi. Information department (HMIS) may need different temperature grades
for their electronic equipments to maintain their efficacy.
vii. Conference rooms and training departments are not operative for 24
hours so these departments should have controlled air- conditioning
systemviii. Similarly, consultants clinics air-conditioning should be controlled
according to their operational timings.
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FINANCE DEPARTMENT
Submitted to Dr. Faisal Haq
By
Dr ZahraSana Makarram
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OBJECTIVESFront Office:
To provide appropriate information to the patients and their attendants.
To establish sound public relationship and to keep basic details of patients.
Admission Department:
To admit, or register all individuals when they enter a hospital for tests,
treatment, scheduled surgery or emergency treatment.
To serve the dual functions of getting information required for hospital
records, and giving information, advice, encouragement, and reassurance to
the patient.
Health Information Management System:
Processing the information that results in the data record for each patient
encounter.
Ensuring that the medical record contains the required documentation
(content).
Data processing Department:
To manage the computerized information that is collected from various
departments in the hospital.
To assist surveillance staff by accessing birth defects information that is
stored in computer format.
Accounts Department:
To Keep track of transactions and recording revenue and expenses are
important business processes.
To record, analyze and retrieve critical financial information that can be
used to determine the hospital's financial status and provide reports and
insights needed to make sound financial decisions.
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Department of Treasury (Cash and Credit Management)
To maintain a booth for the purpose of receiving patient payments and
departmental deposits.
To performs daily rounds to collect payments from hospital departments.
To Post departmental charges to hospital patient system on daily basis.
To provide daily reports to Accounting on cash collections.
To Locate and notify customers (who were patients at the hospital) of
delinquent accounts by mail, telephone, or personal visit to solicit payment.
To receive payment and posting amount to patient's account.
To prepare statements if customer fails to respond.
To initiate repossession proceedings or service disconnection.
To keep records of collection and status of accounts.
POLICIES OF FINANCE DEPARTMENT (FD)Finance staff should complete a training program on fraud and abuse issues,
which is designed to ensure compliance with the requirements of anti-fraud
regulations, including, without limitation, adherence to proper coding and
billing procedures.
Payment must be for tangible services.
Any complaints should be followed up.
Where CFOs (Chief Financial Officers), or an external fraud team, undertake
an investigation on behalf of the Hospital, it is the Hospital's policy to
ensure that they are given unrestricted access to all personnel and
documents as required.
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When fraud has been discovered the Director of Finance is also responsible
for ensuring that the appropriate sanctions are taken and that financial
redress is sought. Redress will always be sought where possible.
FD must have written procedures for each position in the Department,detailing the employees' responsibilities.
Employees should maintain the highest standards of professionalism. The
reputation of the Hospital is paramount and officers must not bring it into
disrepute by any of their actions.
All work should be conducted applying proper standards of fairness and
without discrimination in accordance with the current Equal Opportunities
Policy.
Employees should undertake all work with an open mind. Information
obtained should be assessed without preconceptions.
PROCEDURES OF FINANCE DEPARTMENT
FD creates Department policies.
The Finance Department advises the CEO (Chief Executive Officer) on
financial policy and long-range planning.
FD provides financial counseling and assistance to patients.
Thefinancial managementteam support managers within the Hospital,
providing reports and analysis on expenditure and income throughout the
year, setting budgets and providing financial information and support.
Corporately, the team provide Hospital wide reports on the financial
performance of the hospital to the senior management team and theHospital Board.
Thefinancial accountsteam manages the hospitals cash, and deals with the
payment of creditors, collection of income, internal controls and production
of statutory accounts. The section also manages the hospitals charitable
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funds and undertakes the administration relating to the private patient and
overseas patients work done in the hospital.
The sales ledgerteam section ensures that the income due to the Hospital is
received. The initial stage is the production of an invoice, and then creditcontrol procedures are instigated if the debt is not paid within the agreed
timescales.
The accounts payable team is responsible for ensuring that the invoices that
the Hospital receives are entered onto the finance system. Invoice payment
is processed within this department, together with any supplier enquiries.
The general office is the public face of the Finance Department. The office
itself is the point of contact for patients travel claims and property, as wellas providing services to staff.
Theperformance managementteam assists in negotiation, pricing and
monitoring of the Hospital's contracts. They also produce reference costs
for the Hospital, which identifies the Hospital's costs for all procedures
performed in the previous year.
A member of the Finance Department sits on every planning board; this
affords the Department a great opportunity to infuse the financial
perspective into every operation.
HOSPITAL'S ANTI-FRAUD BYLAWS
Separation of duties. No employee should be responsible for both
recording and processing a transaction.
Access controls. Access to physical and financial assets and information, as
well as accounting systems, should be restricted to authorized employees.
Register accountability. Only a few employees should be assigned to one
register simultaneously, and only one at a time if possible.
All employees should log in their employee number when entering a
transaction.
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Tracking cash variances. All cash overages and shortages should be posted
so trends can be determined. If no patterns are apparent, a shotgun
shortage exists, and a manager or head clerk with access to all registers may
be responsible.
Bad debts, where appropriate, must be written off after being approved by
the CEO.
General journals should be sequentially numbered, supported by narration
and proper authorization
Local Counter Fraud Specialist (LCFS), whom staff may contact confidentially
if they suspect a fraudulent act. The LCFS will be responsible for liaising with
the Human Resources Directorate, on behalf of the Director of Finance,when an investigation into suspected fraud commences. This is to ensure
that existing Hospital policies and procedures in relation to disciplinary
matters are followed.
The Director of Finance and the LCFS are responsible for investigating
suspected frauds in line with the operational directions included within the
Fraud and Corruption Manual
Hospital will use patients' personal health information to monitor or
prevent fraud or any unauthorized receipt of services or benefits.
Different types of sanction can be applied to a proven case of fraud,
including criminal, civil and disciplinary action. Sanctions will always be
taken where fraud is proven. Where fraud is proven this will be reported
internally within the Hospital so as to raise the awareness of fraud and to
assist in the attempts to deter fraud
Employees must follow fraud and abuse avoidance programme, encoded in
Fraud and Corruption Manual. Access to the Fraud and Corruption Manual is
restricted to the Director of Finance and the LCFS, so as to prevent staff
from knowing how to commit fraud.
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DEPARTMENTAL WORK FLOW
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INTERDEPARTMENTAL HIERARCHY
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STAFFING
S.No Hierarchal Level No. ofStaff
01. Departmental Heads 03
02. Managers 06
03. Supervisors 04
04. Clerks Admission Clerks
(4+3+2) Front Office Clerks
(3+2+2) Account Clerks (6) Cashiers (3+2+1) Recovery Team Staff
(6) HMIS Clerks (4) Data Processing
Clerks (4+2+2)
46
Working Shifts:
1st
Shift: 08:00am - 04:15pm
2nd
Shift: 04:00pm - 2:15am
3rd Shift: 12:00am - 08:15am
Office Closing Time:
Daily
1:00pm -2:00pm (lunch break)
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SOURCES OF REVENUE (FUNDING) Operating Revenue: delivery of patient care
Gross Patient Service Revenue (GPSR)
Net Patient Service Revenue (NPSR)
Other Operating Revenue: non patient care activities
Cafeteria sales
Gift shop sales
Parking garage fees
Space or equipment rentals
Research grants
Gains/Losses: peripheral business activities.
Investment Income (marketable securities or donations).
Unrestricted Donations.
HOSPITAL BUDGETING
Types of Budgeting
5 types of hospital budgets:
Expense Budget
Revenue Budget
Operating Budget
Capital Budget
Cash Budget
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Expense Budgeting
The expense budget is the amount of money each department expects to
payout.
These expenses include salaries, supplies, and other various expenses.
There is the monetary resource departments must stay within.
Revenue Budgeting
The revenue budget is a forecast of the income a hospital expects to receive
for the budget period.
The preparation of the revenue budget entails the projection of patientservice revenues, other operating revenues and non-operating revenues.
Total patient service revenues are calculated by multiplying the expected
service volume in each revenue center by the charge per unit of service.
Finance department needs to decide what percentage of price increase will
be needed to produce the desired "bottom line".
Non-operating revenues are included contributions and interest from
investments.
Contributions are sometimes difficult to project while interest on
investments is an important part of the non-operating revenues.
Operating Budget
The operating budget is composed of the expense budget and revenue
budget.
It lists, for the upcoming fiscal year, anticipated income by source, and
anticipated expenses by natural classification such as salaries, supplies, and
utilities.
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Administration always pursues a larger revenue budget than expense
budget, therefore projecting a profit on the bottom line.
The profit is used to finance the capital budget.
Capital Budgeting
The capital budget summarizes future plans for acquisitions of plant
facilities and equipment.
Hospital determine how much of its' capital plan has to devote to renovate
and to expand the project.
Management also examines the hospital's operating performance and
current financial status to see whether future financing is needed.
Capital budgeting is done in three steps:
Identify capital needs
Regarding financial allocations, prioritize the equipment
Managing capital needs
Cash Budgeting
The petty cash is essential for any business or organization to run its
errands.
Cash flow is reviewed on a monthly basis to enable administration to
foresee cash shortages and seek possible financing if necessary.
The cash flow statements basically indicate the difference in the balance
sheet accounts.
The reader focuses on how the debt is being used. For example, if the
hospital shows operating losses, working capital increases, and increases in
capital expenditures the funds will probably have been generated by long-
term or short-term borrowing.
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The cash flow statement helps determine how debt is being used by the
hospital.
Financial managers make sure that they do not spend too much time on
deciding how to get cash rather than how to invest and manage what theyhave.
Higher interest rates will also generate extra funds.
Budgeting of Finance Department
Departments Required Expense BudgetAllocation of Required
Expense Budget
Front office 15% Salaries 12%Supplies 3%Admitting 17%
Salaries 14%Supplies1%Equipment 2%
Health management
information (HIMS)25%
Salaries 16%Supplies2%Equipment 4%Utility 3%
Data processing 14%Salaries 10%Supplies2%Equipment 2%
Accounting 15% Salaries 13%Supplies 2%Cashier
Credit/Collector15%
Salaries 11%Supplies1%Other Expense 3%
Allocation of Budget by Department
Department Expense Budget Revenue Budget
Governing
board/authority
Salaries
2.7%Supplies
0.3%Subtotal
3%
Subtotal 0%
Medical committee Salaries
4.7%Supplies
0.3%Subtotal
5%
Subtotal 0%
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Department Expense Budget Revenue Budget
Finance Salaries
13%Supplies
1%Subtotal
14%
Subtotal 0%
Nursing Equipment 2%
Salaries 9%
Supplies 2%
Medicine 1%
Education 2%
Subtotal 16%
Patient service revenues 47%
Other operating revenues 0%
Subtotal 47%
Support services -
general
administration
Equipment 2%
Salaries 13%
Supplies 2%
Education 2%
Subtotal 19%
Subtotal 0%
Ancillary Depts Equipment 4%
Salaries 9%
Supplies 1%Medicine 2%
Education 2%
Subtotal 18%
Patient service revenues 4%
Other operating revenues 16%
Subtotal 20%
Medical Staff
Depts
Equipment 3%
Salaries 13%
Supplies 2%
Medicine 1%
Education 2%
Subtotal 21%
Patient service revenues 30%
Other operating revenues 3%
Subtotal 33%
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Department Expense Budget Revenue Budget
Marketing Salaries 3%
Supplies 0.5%
Training 0.5%
Subtotal 4%
Subtotal 0%
Total 100 % 100 %
Allocation of Costs between Departments
Department Percentage of costs Sub-departments & percentage of costs
Governing board/authority 3% -
Medical committee 5% -
Finance 14% Data processing 1%
Accounting 2.38%
Admitting 2.38%
Front office 0.15%
Cashier /Credit/Collector 2.38%
Health management information(HIMS) 3.5%
Nursing 16% Nursing education 2%
Inpatient 5%
Central Sterile Supply Department 2%
Operation Room 2%
Outpatient department 3%
Emergency Department 2%
Support services - general
administration
19% Medical Records 4%
Human Resource 5%
Environmental 2%
Maintenance 2%
House Keeping 2%
Social Services 2%
Dietary 2%
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Department Percentage of costs Sub-departments & percentage of costs
Ancillary Depts. 18% Radiology 6%
Pharmacy 4%
Laboratory 8%
Medical Staff Depts. 21% Medicine 7%
Surgery 6%
Obstetrics/Gynecology 5%
House Staff 3%
Marketing 4% Marketing plan 4%
Hospitals Budget Calendar
January 2011Jan 16-22 Budget information & training sessions
February 2011
Feb 8 Top down FY12 Operating Budget forecast and Ten Year Models are
completed
Feb 11 Last day for departments to edit and submit budget requests
Feb 18 Populate Operating Budget tools with historical data
March 2011
March 4Budget Team holds initial meeting
April 2011
April 9 Departments complete submission of Operating Budget revisions
determined during reviews
May 2011
May 1 Hospital completes compilation of budget requests and comparison
to Operating Budget Forecast
June 2011
June 16 CEO approves Budget and departments are notified
August 2011Aug 29 Evaluate budget process and follow-up on recommendations
September 2011
Sept 12 Salary recommendations for management staff are completed
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Medical Department
Prepared by
Komal Daredia
Talat Nur
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Medical Department
Objectives:
1. To diagnose and treat disease or injury for healing, curing or relief2. To educate staff for maintenance of professional standards
3. To conduct research for new medical techniques
4. To provide preventive health care
Policies:
1. To emphasize ambulatory instead of in-patient care
2. To detect diseases as early as possible for optimum recovery
3. To use the least resources consistent with effective care
4. To give patients with common ailment equal consideration
5. To involve patients with medical teaching and research without
discrimination
Programs:
1. General Practitioners Continued Education
2. Community practitioners participation in medical staff seminars and
conferences, doctor rounds and library use.
3. Development of community Health Officers and Medical Assistants
4. Training of patients to live with life term conditions.
Rules:
1. Staff appointments2. Staff engagement in private practice and disciplinary action
3. Confidential nature of medical records information
4. Routine laboratory work needed for patients on admissions
5. Personal use of hospital equipment
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Constraints:
1. Physicians accept a code of conduct respecting human life
2. Medical and Surgical procedure consents (such as for blood transfusions
and interventional procedures)
3. Only registered nurses can receive physicians telephoned orders for
treatment
4. Constraining ethical issues e.g. sterilization
Standards:
1. Regulatory agencies requirement for current membership
2. International standard nomenclature of diseases and operations
3. Standards of staff performance
1. Death rate
2. Average length of patient stay
3. Evaluation of work performance
Environment:
1. Temperature control for scientific equipment
2. Physicians need to work with confidence and a reasonable degree of
freedom
3. Excessive concern on malpractice suits
Physical Facilities:
1. Medical Staff Offices include:
1. Office for Medical Officer
2. Office for Specialists
3. Office for Assistant Administrator
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2. Lounge
1. For medical staff and visiting specialists
3. Conference Room
4. Medical Library
Records:
1. Medical Record Includes:
1. Signed and witnessed consents for medical procedures
2. Administration Record Includes:
1. Staffs completed applications for appointments
2. Professional staff register
3. Minutes and reports of meetings and conferences
4. Medical library card catalogue by subject and matter
Committees:
1. Staff Appointments Committee
1. Reviews applications for staff positions and for annual re-
appointments and make recommendations to Executive Committee
2. Infection Control Committee
1. Implements aseptic measures and remedies deviations from them
2. Responsible for isolation of infectious patients
SWOT Analysis
1. Strengths
1. A diverse pool of qualified specialists
2. Weaknesses
1. High turnover of nursing staff
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3. Opportunities
1. Increased demand of quality care and private sector hospitals
4. Threats
1. Uncertain political conditions of the country
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Organogram
Interdepartmental Hierarchy
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Procedures:
Protocols:
General Guidelines
1. Procedures should be in black and white
2. Should be grouped according to body systems
3. Administration procedures include:
1. Appointment to medical staff, obtaining specialists opinion,
conveying meetings, arranging conferences, withdrawing library
books
4. Each procedure may include:
1. Equipment/Instruments and material needed, preparation of patient,
place of performing procedure and staff, length of time needed.
Pre-Anesthesia Assessment
1. The pre-anesthetic evaluation is defined as the process of clinical
assessment that precedes the delivery of anesthesia care for surgery and for
non-surgical procedures.
2. Involves the assessment of information from multiple sources e.g. medicalrecords, patient interviews, physical examinations, and findings from
preoperative tests
3. At a minimum, a pre-anesthetic physical examination should include:
1. 1) An airway examination
2. 2) A pulmonary examination to include auscultation of the lungs and
3. 3) A cardiovascular examination
Pre-Anesthesia Assessment
1. Timing
1. Guided by considering combinations of surgical invasiveness and
severity of disease
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Surgical Invasiveness Severity of
Disease
Timing of Evaluation
High surgical invasiveness Any severity of disease Prior to day of surgery
Any surgical invasiveness High severity of disease Prior to day of surgery
Low/Moderate surgical
invasiveness
Low severity of disease On/Before day of
surgery
Informed Consent
1. Informed consent is the process by which a fully informed patient can
participate in choices about his/her health care. It originates from the legaland ethical right the patient has to direct what happens to his/her body and
from the ethical duty of the physician to involve the patient in his/her
health care.
Elements of a full Informed Consent
1. The nature of the decision/procedure
2. Reasonable alternatives to the proposed intervention
3. The relevant risks, benefits, and uncertainties related to eachalternative
4. Assessment of patient understanding
5. The acceptance of the intervention by the patient
What is adequate information?
6. Reasonable physician standard: what would a typical physician say
about this intervention?
7. Reasonable patient standard: what would the average patient need
to know in order to be an informed participant in the decision?
8. Subjective standard: what would this patient need to know and
understand in order to make an informed decision?
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Where is informed consent needed?
9. Surgery, anesthesia, and other invasive procedures
10. For a wide range of decisions, written consent is neither required or
needed e.g. a man contemplating having a prostate-specific antigenscreen for prostate cancer should know the relevant arguments for
and against this screening test, discussed in layman's terms
What happens when a patient cannot give informed consent?
11. A surrogate decision maker consents if patient is determined to be
incapacitated/incompetent to make health care decisions
What is presumed /implied consent?
12. The patient's consent should only be "presumed", rather thanobtained, in emergency situations when the patient is unconscious or
incompetent and no surrogate decision maker is available
While the principle of respect for person obligates you to do your best to
include the patient in the health care decisions that affect his life and body,
the principle of beneficence may require you to act on the patient's behalf
when his life is at stake.
Sterilization & Disinfection
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1. Contamination1. The soiling or pollution of inanimate objects or living material with
harmful, potentially infectious or other unwanted material
2. Decontamination1. A process which removes or destroys contamination so that
infectious agents or other contaminants cannot reach a susceptible
site in sufficient quantities to initiate infection or any other harmful
response
3. Cleaning1. A process which physically removes infectious agents and the organic
matter on which they thrive but does not necessarily destroyinfectious agents. Cleaning is an essential prerequisite to ensure
effective disinfection or sterilization
4. Disinfection1. A process used to reduce the number of viable infectious agents but
which may not necessarily inactivate some microbial agents, such as
certain viruses and bacterial spores
5. Sterilization1. A process used to render an object free from viable micro-organisms
including viruses and bacterial spores
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Classification of infection risk associated with the decontamination of
medical devices
Risk Application of item Recommendation
High 1. In close contact with a break in the
skin or mucous membrane
2. Introduced into sterile body areas
Sterilization
Intermediate 1. In contact with mucousmembranes
2. Contaminated with particularly
virulent or readily transmissible
organisms
3. Prior to use on immune-
ocompromised patients
Sterilization/Disinfection
Low 1. In contact with healthy skin
2. Not in contact with patient
Cleaning
1. Devices designated for single-use only must never be re-processed
2. Packaging and dispatch of contaminated items
1. double package the device in appropriate packaging
2. give prior warning to the intended recipient
3. clearly label equipment to indicate that it is contaminated
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3. Receipt of contaminated items in decontamination area
1. Items will be received into the designated dirty items section of the
decontamination area
4. Choice of decontamination method
1. The manufacturers instructions
2. The nature of the contamination
3. the ultimate use of the item
4. the heat, pressure, moisture or chemical tolerance of the item
Safe handling and disposal of sharp items
Type of equipment ________________ Manufacturer _________________
Description of equipment____________________
Other identifying marks _____________________
Model No _______________ Serial No __________________
Fault __________________
Is the item contaminated? Yes* No Don't know
*State type of contamination: blood, body fluids, respired gases, pathological
samples, chemicals (including cytotoxic drugs), radioactive material or any other
hazard: ________________________
Has the item been decontaminated? Yes No Don't know
What method of decontamination has been used? Please provide details
Cleaning ______________________
Disinfection ______________________
Sterilization ______________________
Please explain why the item has not been decontaminated:
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______________________
Procedures
Approximate Time
Procedure Surgery Time Recovery Time
Caesarean Section 30 minutes to an hour 1-2 hours
Laparoscopic
Appendecetomy
45 minutes to an hour 1-2 hours
Laparoscopic Gallbladder
Surgery
An hour 1-2 hours
Cardiac By-pass Surgery 4-5 hours 1-2 days in ICU
Joint Replacement Surgery 3-4 hours 2-3 hours
Staffing Norms
Efficient OR Staffing
Maximize OR Efficiency by minimizing hours of over-utilized OR time1. Under-utilized OR Staff
1. Staffing is planned from 7 AM to 3 PM
2. An ORs last case of the day ends at 1 PM
3. There are 2 hrs of under-utilized OR time
2. Under-utilized time is from 1 PM to 3 PM
3. Over-utilized OR Staff
1. OR staffing is planned from 7 AM to 3 PM
2. ORs last case of the day ends at 6 PM
3. There are 3 hrs of over-utilized OR time
4. Over-utilized OR time is from 3 PM to 6 PM
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VIRTUAL
HOSPITALFRAMEWORK:
NURSING IS..
The use of clinical judgment in the provision of care to enable people to improve,
maintain, or recover health, to cope with health problems, and to achieve the best
ossible quality of life, whatever their disease or disability, until death.(Royal College
Nursing)
We who are nurses are inheritors of a great tradition. It is ours toguard, to strengthen, to enlarge where needed, and to equip ourselves
worthily for so doing. M. Adelaide Nutting (1939)
Nursing is both an art and a science and this is evident in the application of
scientific knowledge and principles, in the assessment of patients' needs, in the
development and implementation of a care plan, and in the evaluation of patient
and family responses.
By ;
Dr Sheikh Sajjad Ali.
10102
Hospital Administration.
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SUMMARIZED HISTORY OF NURSINGNightingale developed and used her coxcomb diagrams, which are credited with
having spawned the use of pie charts, to identify the differences nurses care
made in the lives of British soldiers during the 18541856 Crimean war. However,
what was most unusual and unique was howshe presented her data to demonstrate the number of preventable soldier deaths
before and after the advent of nurses care. Trained nurses, indeed, did make a
quantifiable difference in the lives of the British soldiers.
Accordingly, the death rate of soldiers, resulting from disease and infections,
decreased from 47% before the introduction of trained nurses to 2% after their
arrival (Florence Nightingale Museum, 18541856).
NURSING DEPARTMENT:
We believe nursing is concerned with the wellbeing of the total person.
Through its unique contribution, nursing can and must be an effective
social force in promoting the quality and availability of health care services
for all persons and worth.
OBJECTIVES:
To provide path to nurses to ensure delivering of high quality of nursing
care.
To collaborate with other paramedical staffs to ensure the integrated and
holistic care to the patient.
47
2
-100
-80
-60
-40
-20
0
20
40
60
No Train Nurses Trained Nurses
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To provide assistance to physician to carry procedure as prescribed by
them.
To promote leadership in nursing practice, education, administration, and
research. To establish and implement the philosophy, standards, policies, rules and
procedures for the nursing service.
To ensure appropriate distribution of duties and responsibilities among the
nursing staff at various levels.
To periodically appraise the performance of nurses and carry out regular
nursing audits.
To estimate the requirement for nursing personnel, appointment of
competent nurses and establishes policies and programs for their
orientation, placement, on the job training and supervision.
POLICIES:
To achieve the highest level of individual's health.
To encourage families to participatein the patients care. E.g. hygiene care,
wound care, nutrition etc.
To accommodate patient with same problem in the same areas.
To focus on evidence-base practice. To ensure healthy work environment
MISSION:
Partnership with the people to ensure equity, quality, leadership in providing
compassionate focuses on the unique needs of patients and their families.Service commit to:
Treating patients with compassion andrespect for their human dignity,individual valuesand religious beliefs.
Being responsive to the customer's needs while making decisions that arebased upon sound,ethical business principles andpractices.
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Caring equally for all without regard to race, color, national origin, disability,age, religion, sex or any other basis prohibited by law.
The provision ofemergency services to the people of our community regardlessof their ability
to pay.
Working together interdependentlyto serve our clients better
Continuing Education
VIRTUAL HOSPITAL believes that continuing education for all staff is essential to
our future.
A minimum oft 0.7 Continuing Education Units (CEUs) are required (7 contact hours)
annually. One tenth of a CEU equals one hour of education. One contact hour equals
one hour of education.A maximum of ten contact hours related to formal credits are allowed.
Purpose of the Bylaws
Bylaws provide for the governance of the professional nursing staff of
VIRTUAL HOSPITAL, a framework for its operation, and are reflective of the peer
review process. These Bylaws describe the staff and the responsibility of the
professional staff within a shared governance model. The professional nursing
staff is a component of VIRTUAL HOSPITAL, and not a separate legal entity or
organization.
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Description of Nursing Services :Nursing services are provided through the followingdepartments:
Birthing CenterProvides a family-centered approach to the birthing
process through labor,delivery, post-partum, and nursery care. Cardiac RehabilitationA supervised outpatient program that includesexercise, life-style
changes, education and emotional support for people who have had acardiac event. Thisprogram is medically supervised and individually designed to enhancethe patients quality oflife.
Clinic Serviceso Family Practice Clinics - Provides preventive health services,counseling, well person
check-ups and many other services .o General Surgery Clinic - Provides a variety of surgical procedures .o Women's Clinic - Provides obstetric, gynecology and urogynecologyservices.
EducationEvaluates the organization's training needs and develops andfacilitates programs
for staff training and competency assessment to support quality andpositive patient and serviceoutcomes.
Emergency DepartmentProvides Level IV trauma care in twotrauma beds and four
emergency treatment rooms. The emergency department is staffedwith specially educatedregistered nurses 24 hours a day. Emergency physicians provide 24 hourin-house coverage.
Home and Community HealthProvides quality, comprehensive in-homehealth services that
are designed to decrease the need for institutional care and help promotepatient independence,serving a 33 mile radius surrounding Waverly. Community healthservices, including flu and pneumonia clinics, blood pressurescreening, adult hepatitis B immunizations, tobacco cessation and
prevention programs. Infection Prevention/Occupational Health/Employee HealthInfectioncontrol is responsible
for establishing WHC policy and providing education on prevention ofinfections in staff,visitors, and patients.
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To evaluate the Performance:
The following process as developed by the members of the Nursing Performance
Improvement Council and adopted by the staff defines the process of
performance evaluation as PEACHS.
P= Problem IdentificationE= Establish PI Steps
A= Apply the Change
C= Check the Change
H= Have the Process Revised
S= Status Check
Meeting Times:
Nursing councils shall meet monthly and function consistent with By-laws.
Minutes will be taken, duly recorded and distributed to the nursing staff. Meeting
times and length will be specifically approved by the majority of the Council
members present.
NURSING EDUCATION:
Provide both the foundation of general education and a nursing curriculum
that emphasizes the knowledge, skills and values.
Faculty and students establish a partnership wherein the faculty provides
diverse learning opportunities and the student accepts responsibility for
their own learning.
Systems comprise the structure:
Student System: accept responsibility for their own learning
Nurse System: when implementing safe, effective patient care within
various roles.
Health Care System: Safe, quality health care is attained and continuously
improved utilizing the expertise of health
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PROGRAM:
Infection Control
Grievance
Medication Basic Life Support
Vital signs
Operation Theater (Patient handing over and receiving)
ROTA/ ROTATION
Orientation
Infection control:
The highest incidence HAI is observed amongst invasive procedures.CDC, 2 Millions pts in US developed HAI.
90k pts died.
4th leading cause of death in US.
Cost additional $4-5 billions/yr.
Role of Nursing Personnel in prevention of HAI:
Nursing background helps them in there job with infection control. The physician might be more in tune with the disease and its process.
The nurse is more in tune with the hospital policy development &
compliance ,would like to see.
More programs to educate nurses in epidemiology.
Risk Factors for HAI:
Low resistance of patients to infections.
Contact with infectious persons. Invasive procedures/interventions.
Inappropriate antimicrobial usage.
Drug resistance.
Contaminated environment
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High Risk Areas in Hospital:
Nurseries.
ICUs.
Dialysis Units. Organ transplant.
Oncology ward.
OTs(Delivery rooms,Post Op Rooms)
Hospital Infection Control Program
Monitoring:
Microbiological surveillance.
Investigation & Control of outbreaks if any. Monitoring Of anti microbial resistance.
Providing facilities to the hospital staff to maintain good infection control
Educating/training programs for hospital staff.
Provisions for staff health activities.
Written documents outlining the various infection control policies.
Effective Control Measures:
Hospital planning (Riggs pattern wards, isolation room ICU, air lock systems,corridors cleaning, hand washing, natural ventilation)
Administrative Control:
(Rounds, training to nurses, health education, hosp inf. control committee,
people, aseptic techniques, disinfections, antibiotic policy, CSSD, laundry, ICU,
house- keeping)
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Grievance:
is used to describe circumstances where an employee wishes to raise a
matter of concern in connection with his or her employment, including the
application of terms and conditions of service.Common issues which may give rise to a grievance (not intended to
constitute an exhaustive list) include; a decision taken by your manager,
terms and conditions of employment, health and safety, new working
practices, organizational change and equal opportunities.
Stage 1 - Informal - Let the Trust know the nature of your grievance .
through a informal conversation or in writing
manager will seek to resolve the grievance informally first .
Stage 2 - The Formal Grievance Process
Normally be done within 14 calendar days of it becoming clear that theissue has not be resolved Informally.
Manager must invite the employee to a meeting to discuss the grievance,
normally be confirmed within 7 working days.
Human Resources representative must be present at this meeting.
Stage 3 - The Right To Appeal
employee believes that their grievance has not been satisfactorily
writing summarizing appeal to the Deputy Director of Human Resources,
within 14 calendar days following the date of the decision letter.
Appeal meeting= not less than 7 days.
Medication:
Only RNs and Physicians are allowed.
Strict action would be taken if uncertified personnel will attempt to
administer drugs to patient.
Basic Life Support: (BLS).
Life saving technique.
Every new nurse/staff.
Every 3months for 2 days and validity for 2 years.
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ROTATION:
for employees in learning the subtleties of some tasks and thus end up
increasing the physical demandsemployees to be physically able to perform the most difficult tasks
Education and training of workers for new jobs
Orientation:
orientation should include provision of adequate and appropriate informationregarding local procedures and departmental orientation.
staff should be nominated to show the new employeearound the department.Within the first two months of employment, the line manager should meet
with the new appointee to establish their performance objectives, standards
to met, and any training needs .
All new staff should have completed their local orientation checklist .Orientation of ward, policies and procedures, different system , off basic
skills .
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Organogram Of Nursing Department:
Clinical Nurse Manager/ Nurse Lead responsible for an entire
directorate/department (i.e.Surgical,MedicalDiagnostic & Imaging
etc.) least
Modern Matrons is responsible for overseeing all nursing within a
department or directorate.
Healthcare Assistants
Staff Nurses Senior staff nurses
Junior/Deputy Sister; Charge Nurse; Ward Manager
Sister/Charge Nurse; Ward Manager
Senior Sister; Charge Nurse; Senior Ward Manager
CEO
COO
Chief Nurse
Asst.Chief NurseServices.
Coordinator Clinicalareas
Surg/Med/Obs/Gyn
Coordinator Specialareas.
Opd/OR/Minor
Asst.Chief NurseTraining &Research.
CMO
CFO HR
http://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/wiki/Surgical -
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Non Nursing Duties:
Chief
Nurse
Nurse III
Nurse II
Nurse I
Nurse III
Nurse II
Nurse I
Nurse III
Nurse II
Nurse I
Physicians'secretary
Ward clerk Porter
Billing clerk
Medico-social
worker Pharmacist
Recordkeeper.
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STAFFING:
1. No UNIVERSAL FORMULA which guarantees safe and effective patient care.
2. Unpopular methods include
G.R.A.S.P ----- General responsibility assignment software pattern.P.I.N.I ------ Patient intensity for nursing index.
N.I.S.C.M ----- National info system for Crisis management.
3. Top Down Planning:
Historical Data
Bed occupancy and throughput.
4. Formulae dependant on patient dependency and work load.
Skill Mix:
CSSD:Central Sterile Supply Department
Include processing and sterilization of syringes, rubber goods [catheters,
tubing], surgical instruments, treatment trays and sets, dressings etc
SPECIAL TRAININGCICU/ICU
Ventilator care, Critical carecourses
ADDITIONAL Skills
Special Care Unit ACLS, SCU training
BASIC SKILLS FOR NURSESGeneral wards
I/V cannulation,Medication, BLS
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Advantages
-Quality improvement.-Sustainable process optimization
-Reduction of administrative responsibility
-Assurance about compliance to all relevant norms
(ISO EN )
Operating Room Nurse Objectives
Candidate required for management of surgical procedures during and
after major/minor operations.Checklist to monitor the physical plan of the operating room
Communication lines, both interdepartmentally and interdepartmentally,
to provide for total needs of the patient.
Maintain a record
excellent inter-personal skills
Should have 5 years of experience in this field
Opd Nurse:
An OPD Nurse is one that works in the Out Patient Department of the hospital,
where patients receive diagnoses and/or treatment but do not stay overnight
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EMERGENCY Room Objective:
Working within trauma units, emergency room/critical care units,
evaluating acute responses, providing emergency medical, preparing
patients for stress testing and echocardiography, patient referrals and
managing assessments.Levels Of Care:
Level 1= minimal care
Level 2= intermediate care.
Level 3= total care.
Level 4= specialized care.
SWOT ANALYSIS:
Strengths:Qualified Nursing staff and experienced Nursing managers
Standardized care
Improved quality of care
Improve leadership.
set of documents
Good clinical governance
Existing skills (high level) of some Departmental nursesTake pressure off General Practitioners and Specialists
Weaknesses:
Increase Turn over of staff.
Resources required to educate and supervise Nurse Practitioners
Potential for staff to leave organization after training
Lack of consistent clinical practice (in some specialty areas)
Low ability to retain the professional
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Opportunities: Improve response time
Expand services
Decrease length of stay
Improve links between health professionalsDevelop infrastructure to strengthen nursing health care and increase
efficiency in hospital sector.
Societal changes
Technological development
Challenges:
Competitor Problems.
Lack of knowledge understanding of the Nurse Practitioner role
Funding / cost
Medico legal issues
Workload for candidates
Demographic change
Raising population expectations to health system.
Improvement Nursing through staffing care:
Improvement of technique in nursing care.
Time and work assignment.
Need to increase the number of staff.
Training of auxiliary workers.
Evaluation of performance on individual basis.
Optimum utilization of staff through supervision.
Analysis of task performed by different categories of workers
Shifting Of Nursing Personnel: (Vary in different Hospitals)
Morning Shift 8am 2pm.
Evening Shift 2pm -8pm.
Night Shift 8pm-8am.
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Budget:
Nursing Salary & wages are 68% ofthe nursing direct expense budget.
Nursing Salary & Wages are 15% of the hospital direct expense budget
The Clinical Practice Guideline and Education and Mentoring Working Parties
will provided support for the development of nurse practitioner roles within
existing budgets.
Participation Of Chief Nurse in budget preparation leads to cost consciousness.
-Increase cost effectiveness.
-Efficient use of resources.
Budget primary concern with:
Personnel salaries
Supplies.Equipment outlay.
Capital expenditure.
Factors affecting:
Type of hospital & level of care.
Personnel policies.
Training & research programs.
Authorized bed capacity
Proportion of nursing care1. Turnover rate.
2. Standard of nursing care.
3. Physical layout of hospital
4. Methods of assignments.
Budgeting Staff
Daily FTE required-used to plan daily staffing
Total Patient Care Hours = Daily Hours of Care
365
For 8 hour shifts Daily Hours/8
For 12 hour shifts Daily Hours/12
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PHARMACY DEPARTMENT
Saba Ilyas Qureshi
Roll No: 11071
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What is a Hospital?
Hospital is a complex organization and an institute which provides health to
people through complicated but specialized scientific equipments and a
team of trained medical staff educated in the problems of modern medicalscience
Thus the hospital is a specialized body where the patient care is the focus
point and about which all activities of the hospital revolve
Salient Features of Hospital Pharmacy
Usually found within the premises of the hospital.
Usually stock a larger range of medications, including more specialized andinvestigational medications (medicines that are being studied, but have not
yet been approved), than would be feasible in the community setting.
Provide medications for the hospitalized patients only, and are not retail
establishments.
Does not provide prescription service to the public.
Some hospitals do have retail pharmacies within them which sell over thecounter as well as prescription medications to the public, but these are not
the actual hospital pharmacy.
What does the Pharmacy department do?
Administrative
P & T committee
Hospital Formulary
Educating staff
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Clinical Services / Patient Care
Patient counseling
Poison and drug information
Information Service
Drug Distribution and Control
MM and inventory control
Automated pharmacy services
Quality & Performance Improvement
Pharmacy improvement programs
Medication Safety
Adverse drug reactions (ADR)
Objectives
To provide at all times, medications of the highest standard in appropriate
dosage forms consistent with the needs of the patients in collaboration withthe medical staff;
To rationalize drug utilization and procurement in colla